On a barium swallow, classic achalasia often shows which imaging appearance?

• A. A dilated esophagus with a tapered, smooth narrowing at the gastroesophageal junction (bird-beak)
• B. Corkscrew esophagus
• C. A smooth, regular narrowing of the distal esophagus
• D. A dilated esophagus with a narrowed gastroesophageal junction that creates a bird-beak appearance on radiographs with a residual contrast column

Answer: (D)

Classic achalasia on a barium swallow shows a dilated esophagus that tapers smoothly at the gastroesophageal junction, producing the bird-beak appearance. The narrowing is due to a nonrelaxing lower esophageal sphincter, and the barium often pools just above that narrowed segment, creating a residual contrast column. This combination—proximal dilation with a distal, smooth taper at the GE junction and accumulation of contrast above it—best matches the typical imaging pattern of achalasia. In contrast, corkscrew esophagus points to diffuse esophageal spasm, and a smooth distal narrowing without dilation suggests a benign stricture rather than achalasia.